Acute treatment of variceal haemorrhage

• ABC: patients should ideally be resuscitated prior to endoscopy
• correct clotting: FFP, vitamin K
• vasoactive agents:
  • terlipressin is currently the only licensed vasoactive agent and is supported by NICE guidelines. It has been shown to be of benefit in initial haemostasis and preventing rebleeding
  • octreotide may also be used although there is some evidence that terlipressin has a greater effect on reducing mortality
• prophylactic IV antibiotics have been shown to reduce mortality in patients with liver cirrhosis. Quinolones are typically used. NICE support this in their 2016 guidelines: 'Offer prophylactic intravenous antibiotics for people with cirrhosis who have upper gastrointestinal bleeding.'
• both terlipressin and antibiotics should be given before endoscopy in patients with suspected variceal haemorrhage
• endoscopy: endoscopic variceal band ligation is superior to endoscopic sclerotherapy. NICE recommend band ligation
• Sengstaken-Blakemore tube if uncontrolled haemorrhage
• Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
  • connects the hepatic vein to the portal vein
  • exacerbation of hepatic encephalopathy is a common complication

Prophylaxis of variceal haemorrhage

• propranolol: reduced rebleeding and mortality compared to placebo
• endoscopic variceal band ligation (EVL) is superior to endoscopic sclerotherapy. It should be performed at two-weekly intervals until all varices have been eradicated. Proton pump inhibitor cover is given to prevent EVL-induced ulceration. This is supported by NICE who recommend: 'Offer endoscopic variceal band ligation for the primary prevention of bleeding for people with cirrhosis who have medium to large oesophageal varices.'